A children’s health policy blog

Emerging Policies on Dental Coverage for Kids

With the final rule on EHBs, another on market reforms, and some additional guidance from HHS, we’re getting a clearer picture of how one important set of benefits—dental care—will work for kids in EHB-covered plans next year. As readers know, those are new private plans in the individual and small group market. For a number of important points on pediatric dental coverage, check out these slides from a recent webinar CCF hosted with the Children’s Dental Health Project.

With the publication of the final EHB rule, we now know that 31 states will use the FEDVIP MetLife High plan as the benchmark for pediatric dental coverage while 19 will use the dental benefits their states offer in CHIP. Find out which one your state chose using State Refor(u)m’s handy table.

Another important question is the extent to which families are expected to purchase dental coverage for their children. Remember that EHBs apply both inside and outside exchanges. When stand-alone dental plans are offered in an exchange or marketplace, other plans need not offer pediatric dental coverage. Families can meet the federal requirement to have coverage by purchasing one of these qualified health plans that don’t include dental coverage—i.e., there’s no federal requirement for families buying in the exchange to purchase the stand-alone dental coverage, even though it will be available if they choose. Some states have considered a requirement for families to purchase this coverage to assure that their kids have dental coverage, or considered at least ways to encourage its purchase.

Outside the exchanges, things work a bit differently. There is no provision of law that exempts plans from offering the EHBs based on the presence of a stand-alone dental plan in the market outside exchanges. Plans have to assure that their customers have access to all of the EHBs, including pediatric dental coverage. Therefore, HHS determined that in order to offer qualified health plans outside the exchange, plans must be “reasonably assured” that their customers have purchased pediatric dental coverage. While technically this is a requirement that insurers must fulfill, in effect it is a requirement on families to obtain pediatric dental coverage if they want to purchase other health benefits in the individual and small group markets outside of exchanges.

Next, there is the question of what affordability protections are available to families when they purchase pediatric dental coverage. This will depend on whether pediatric dental benefits are offered as part of a plan that covers all of the EHBs or as a separate, stand-alone policy. When the pediatric dental benefit is embedded, the range of ACA affordability protections apply: premium rating must follow the ACA rules and federal subsidies—both premium tax credits and cost-sharing reductions—are available to eligible families. In a stand-alone plan, however, premiums may vary based on health status, age, or other factors (though dental plans tend not to apply such rating factors today). The IRS plans to limit tax credits based on the cost of the second-lowest cost silver plan available to the family—even if it doesn’t include dental benefits. When those silver plans don’t include dental benefits, premium credits will be available to support pediatric dental coverage only for those who purchase particularly inexpensive health plans. And, by law, cost-sharing reductions won’t be paid for stand-alone dental plans.

Another affordability issue families may face concerns the out-of-pocket limit that applies to their pediatric dental coverage. But that discussion will have to wait for another blog post.

All of these intricate issues make planning for kids’ dental coverage in 2014 rather complicated. Nonetheless, some states are considering innovative steps to help make dental coverage accessible and affordable for families. Just as we can’t forget oral health when assessing a child’s overall wellbeing, we shouldn’t ignore dental coverage as we build new ways to cover kids and families starting next year.

Joe Touschner is the Senior Health Policy Analyst at the Center for Children and Families

The Center for Children & Families (CCF) of the Georgetown University Health Policy Institute is an independent, nonpartisan policy & research center dedicated to expanding & improving health care coverage for America’s children and families.